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ORIGINAL ARTICLE Journal of Psychedelic Studies 2(1), pp. 53–60 (2018) DOI: 10.1556/2054.2018.001 First published online March 20, 2018 Inside bad trips: Exploring extra-pharmacological factors

GENÍS ONA*

Department of Anthropology, Rovira i Virgili University, Tarragona, Spain

(Received: June 18, 2017; revised manuscript received: January 16, 2018; accepted: January 17, 2018)

Objective: This study aimed to clarify the influence of extra-pharmacological factors in the etiology of bad trips,a common adverse reaction related to the consumption of psychedelic . Methods: A descriptive approach was adopted. The information was collected using a web-based survey. The survey respondents volunteered to participate based on the condition that they had suffered a in the past. Results: This report reveals some variables that are commonly related to this adverse reaction (i.e., the recreational consumption of drugs, the consumption of drugs in large, open outdoor spaces, or being inexperienced with the ). In addition, we note that some problems, which may be related to bad trips (i.e., mixing drugs, ignorance about the purity, or the dosage), can be solved through harm- reduction strategies. Conclusions: We found certain aspects that could be related to the appearance of a bad trip, but it is not possible to establish a causal connection. We recommend conducting prospective studies with larger samples to collect more information about the role of extra-pharmacological factors.

Keywords: psychedelic, bad trip, drug, adverse reaction

INTRODUCTION Carbonaro et al., 2016; Cohen & Ditman, 1963; Fink, Simeon, Haque, & Itil, 1966; Frosch, Robbins, & Stern, 1965; Glickman Psychedelic drugs like lysergic acid diethylamide (LSD-25), &Blumenfield, 1967; Heaton, 1975; Kleber, 1967; Malleson, 3,4-methylenedioxymethamphetamine (MDMA), and psilo- 1971; Smart & Bateman, 1967; Strassman, 1984), few studies cybin are being investigated again, showing therapeutic poten- specifically focus on bad trips (Barrett, Bradstreet, Leoutsakos, tial for certain psychological disorders, such as post-traumatic Johnson, & Griffiths, 2016; Carbonaro et al., 2016; Cohen, stress disorder (Amoroso & Workman, 2016; Mithoefer et al., 1960; Ungerleider, Fisher, Fuller, & Caldwell, 1968). 2013; Oehen, Traver, Widmer, & Schnyder, 2013) and de- Literature on psychedelic-induced states of consciousness pression and associated with life-threatening illnesses suggests that the extra-pharmacological factors are determi- (Grob et al., 2011; McCorvy, Olsen, & Roth, 2016). There are nant (Grof, 2005; Masters & Houston, 1974; Prepeliczay, dozens of references on this issue, so we suggest reading the 2002; Sumnall, Cole, & Jerome, 2006), because states of following recent reviews: Garcia-Romeu, Kersgaard, and consciousness induced by psychedelics potentiate perception Addy (2016) and Nichols, Johnson, and Nichols (2017). and experience of external stimuli (Grof, 2005). Alongside this therapeutic trend, recent studies have The delineation of these extra-pharmacological factors is begun to challenge the notion that the psychedelics are conceptualized in the notion of “,” that is to say, harmful to mental health (Krebs & Johansen, 2013). On the way the experience is influenced by the individual’s mind- the contrary, we may consider the possibility that the set (set) as well as the surroundings and atmosphere (setting). consumption of these drugs by healthy people in naturalistic In this study, the relationship between bad trips and a contexts could have benefits to mental health (Johansen & delimited list of extra-pharmacological factors will be explored. Krebs, 2015; Ona & Spuch, 2017). We note that all drug users are exposed to some adverse reactions (Grof, 2005; Strassman, 1984). These substances can METHODS exacerbate the psychopathological traits that could cause per- sisting adverse reactions (Cohen, 1960; Johnson, Richards, & Overview Griffiths, 2008; Strassman, 1984). When drug users do not have previous psychopathological traits, they may experience acute An online survey was developed to collect information about adverse reactions like fear, panic, overwhelming anxiety, or bad trips. This was designed with the intention of discovering confusion, which together constitutes what is commonly known as a bad trip. This phenomenon has not been studied * Corresponding address: Genís Ona; Interdisciplinary Psychedelic in depth. While there are important number of studies, which Studies, Medical Anthropology Research Center, Rovira i Virgili address the adverse reactions related to the consumption of University, Avda. Catalunya, 35, Tarragona 43002, Spain; Phone: psychedelics (Abraham & Aldridge, 1993; Bewley, 1967; +34 675 553344; E-mail: genis.ona@e‑campus.uab.cat

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Unauthenticated | Downloaded 09/26/21 04:47 PM UTC Ona what, if any, extra-pharmacological factors are commonly SECTION 1 related to the adverse reaction known as a bad trip. Introduction Basic information about the bad trip. Expected time for completion. Materials Basic instructions. Main investigator contact details. The survey was designed with closed-ended questions with defined response categories. At the conclusion of the survey, participants were also given the opportunity to provide any other comments they wished to on the section topic. The first section of the survey was used to determine SECTION 2 ’ Antecedents participants eligibility. Participants were provided with in- Organic or psychological diseases, if formation about the survey, including the purpose and assur- any. ance of anonymity. Respondents were asked to recall their Prescribed , if any. bad trip and answer the questions about that experience. If they had experienced more than one bad trip,theywereasked to choose the one they considered to be the most significant. The demographic section of the survey asked participants SECTION 3 for information including age, education, occupation, and Context country of residence. Type of context. fi Open outdoor / indoor space. Themainbodyofthesurveyhad ve sections concerning Size of the space. respondents’ medical history, the context of the experience, Number of people in the space. the drug used, the experience, and the after-effects. A sche- Music style, if any. Music volume, if any. matic diagram of the survey instrument is provided in Figure 1. Illumination of the space. The full survey is available from the authors upon request.

Procedure

The survey was hosted online using the Google Forms SECTION 4 Drug platform (docs.google.com/forms) and shared on social Which psychedelic. media with the collaboration of various organizations from Dose. Purity of the drug. Spain and other Latin American countries (e.g., Energy Poly-drug use Control, Caapi, Échele Cabeza cuando se dé en la Cabeza, Previous experience among others). Only drug users who had suffered a bad trip were requested to complete the survey.

Sample SECTION 5 Bad trip A total of 233 volunteers aged between 18 and 54 years Valuation of the experience. (X = 23.6) completed the survey. Two subjects were ex- Positive or negative ending. used, if any. cluded from the study, because the supposed bad trip they Learnings gained, if any. suffered did not emerge in response to the consumption of a psychedelic substance.

Data analysis SECTION 6 Post-effects IBM SPSS Statistics v.21 was used to analyze the survey Long-term adverse reactions, if any. data. The results are reported in percentages. Flashbacks occurrence, if any. Changes in interaction with others. Consumption of the same psychedelic. Ethics Consumption of other psychedelics. Medication used during the days or weeks after the bad trip, if any. This study has been conducted in accordance with the ethical principles set out in the declaration of Helsinki.

RESULTS SECTION 7 Sociodemographic information Sociodemographic information

The majority of the sample reported had completed univer- Figure 1. Schematic diagram of the survey sity studies (64.5%), whereas 14.7% had completed high- school studies and 10.8% had master’s or doctorate degrees.

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About 48.7% of participants were students, whereas The majority of the sample (57.1%) took the drug in open 46.1% were professionals and 5.2% were unemployed. outdoor spaces, whereas 42.4% took in indoor spaces. A majority of respondents reside in Colombia (40.7%), Regarding the size of the space where the bad trip took whereas 11 other nationalities are represented in the place, 63.2% of the sample classified the space as large results [Spain (28.5%), Mexico (11.2%), Argentina with 36.6% of them reporting that the size was “over- (9.1%), Chile (3.4%), Ecuador (1.3%), Portugal (1.3%), whelming.” About 36.8% of the sample classified the space United States (0.9%), France (0.9%), Germany (0.9%), as small with 12.9% of them reporting that this size was Peru (0.4%), and Panama (0.4%); see this information “overwhelming.” in Table 1]. There were less than 10 people in the same space in 44.1% of the cases; more than 10 in 27.7% of the cases; and more Medical history of the sample than 50 people in 13.4% of cases. About 14.7% of the sample reported having being alone during the time of the bad trip. About 78.3% of the sample did not report any physical There was music playing in 78.4% of the cases. About condition before the bad trip. The rest of the sample 26.3% of respondents reported that they liked the music reported (7.3%), hypoglycemia (1.7%), gastritis style, whereas 7.8% did not like it. We do not have (1.3%), (0.9%), atopic dermatitis (0.9%), or information about the remaining 44.3%. In this “music hypothyroidism (0.9%), among others. group,” 37.6% indicated that music was at low volume, Similarly, 76.6% of the sample did not have any psy- allowing for conversation; 23.8% that music was at high chological diagnosis. The remaining 22.4% reported anxiety volume, hindering conversation; 11.2% that music was at (6.9%), depression (6.7%), attention-deficit hyperactivity very high volume, making any conversation impossible; and disorder (ADHD) (1.7%), (1.7%), schizo- 5.6% that music was at very low volume. phrenia (0.8%), or sleep disorders (0.4%). Regarding the illumination of the context, 56.2% of Medications reported to have been consumed before the respondents reported that the visibility was fairly good; occurrence of the bad trip were ventolin (2.1%), salbutamol 32% of the subjects reported the context was dark; 6.5% (1.7%), fluoxetine (1.3%), (0.9%), of the subjects reported there was too much light; and finally (0.9%), and (0.9%), among others. About 5.2% of the subjects reported that the context was very dark 78.4% of the sample did not report any relevant medication (see this information in Table 2). (see this information in Table 1). Drug Characteristics of the context In 50.2% of the cases, the drug was LSD. Then, the drugs Respondents were asked to classify the context of their bad were smoked (14.7%), mushrooms trip as one of three different categories: therapeutic (looking (10.3%), 25i-NBOMe (4.3%), MDMA (3.9%), Salvia divi- for introspection), recreational (with a few friends), and norum (3%), ingested cannabis (2.2%), (2.2%), festive (in or festivals). Most of the sample defined magic mushrooms (psilocybin) (2.2%), 2,5-dimethoxy-4- their context as recreational (55.4%), with 30.3% as festive bromophenethylamine (2.2%), 4-ethyl-2,5-dimethoxy- and 14.2% as therapeutic. As a curiosity, the percentage of (0.9%), (0.9%), San Pedro respondents with psychological disorders were equally dis- () (0.9%), LSA (0.4%), N, N-dimethyltryptamine tributed between the three categories, χ2(26, N = 231) = (0.4%), and 5-methoxy-N-methyl-N-isopropyltryptamine 20.25, p = .77. (0.4%).

Table 1. Sociodemographic information and medical history of respondents Sociodemographic information Age <20 20–30 31–40 41–50 51–60 52 (23%) 144 (62.3%) 28 (12.1%) 5 (2.2%) 1 (0.4%) Education level Primary Secondary Post-obligatory University Master or PhD 2 (0.9%) 21 (9.1%) 34 (14.7%) 149 (64.5%) 25 (10.8%) Occupation Students Professionals Unemployed 113 (48.7%) 106 (46.1%) 12 (5.2%) Country Colombia Spain Mexico Argentina Chile 94 (40.7%) 66 (28.5%) 26 (11.2%) 21 (9.1%) 8 (3.4%) Medical history Organic diseases Non-reported Asthma Hypoglycemia Gastritis Arrhythmia 181 (78.3%) 17 (7.3%) 4 (1.7%) 3 (1.3%) 2 (0.9%) Psychological diseases Non-reported Anxiety Depression ADHD Bipolar disorder 177 (76.6%) 16 (6.9%) 15 (6.7%) 4 (1.7%) 4 (1.7%) Prescribed medication Ventolin Salbutamol Quetiapine Loratadine 5 (2.1%) 4 (1.7%) 3 (1.3%) 2 (0.9%) 2 (0.9%) Note. ADHD: attention-deficit hyperactivity disorder.

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Table 2. Characteristics of the context and the drug used Context Type of context Recreational Festive Therapeutic 128 (55.4%) 70 (30.3%) 33 (14.2%) Indoor/outdoor Open/outdoor Indoor 132 (57.1%) 98 (42.4%) Size Large Small 146 (63.2%) 85 (36.8%) No. of other people <10 +10 +50 Alone 102 (44.1%) 64 (27.7%) 31 (13.4%) 34 (14.71%) Music Music playing Liked style Low volume High volume 181 (78.4%) 60 (26.3%) 87 (37.6%) 55 (23.8%) Illumination Too much light Good visibility Dark Very dark 15 (6.5%) 130 (56.2%) 74 (32%) 12 (5.2%) Drug Which drug LSD Cannabis Magic mushrooms 25i-NBOMe MDMA 116 (50.2%) 34 (14.7%) 24 (10.3%) 10 (4.3%) 9 (3.9%) Dose Low Medium High Not sure 15 (6.5%) 50 (21.6%) 25 (10.8%) 141 (61.1%) Purity Drug analyzed Not analyzed 81 (35%) 150 (65%) Other drugs Not mixed Poly-drug use 76 (32.8%) 155 (67.2%) Previous experience First time Little experience Very experienced 50 (21.6%) 112 (48.4%) 69 (29.9%) Note. LSD: lysergic acid diethylamide; MDMA: 3,4-methylenedioxymethamphetamine.

It is important to note that 60.8% of the sample did not experience (e.g., not to mix different drugs, the importance know the dose (low, medium, or high) they took. Among of selecting an adequate context, not to take drugs, etc.). those who knew the dose, 21.6% took a medium dose, 10.8% a high dose, and 6.5% a low dose. Use of medication Similarly, 65% of respondents were not aware of the purity of the drug. The remainder of the sample did objec- This question refers to the use of medication to stop the bad tive analyses through harm-reduction organizations. trip. About 5.2% of respondents consumed medication with Notably, we found that 67.2% of our sample consumed the intention of terminating the bad trip, and of these, the more than one drug. The most common secondary drug was medications were (1.3%), drugs (not cannabis (24.1%), followed by (6%), (6%), specified) (0.9%), bromazepam (0.4%), (0.4%), or MDMA (0.4%), speed (0.4%), Brugmansia (0.4%), and (0.4%). (0.4%) (see this information in Table 2). After-effects Previous experience About 25.4% of subjects reported long-term , Respondents were asked about their previous experience defined as symptoms or adverse reactions sustained for with the drug. About 48.4% of the sample had little experi- weeks or months. These included anxiety, depression, and ence; 29.9% were very experienced; and 21.6% had never symptoms. taken the drug. About 44.8% of subjects experienced some flashback, which consisted of reexperiencing the perceptual effects Valuation of the experience induced by psychedelic drugs at a later time. Despite this adverse reaction, 64.2% of respondents Subjects had to classify their experience using a Likert-type reported having taken the same drug again. About 65.1% item with seven options, ranging from “it was the worse consumed the same drug along with other substances. experience of my life” to “it was the best experience of my Regarding medication used days or weeks after the bad life.” About 82.3% of subjects classified their experience trip, 6.5% of subjects used , 12% , negatively with 15.1% as the worst of their lives. About and 20% other medications like aspirin or ibuprofen. 17.7% of subjects classified their experience positively with 1.7% as the best experience of their lives. It is important to know if subjects were able to redirect DISCUSSION the bad trip or not. In our sample, 68.5% of subjects could in fact redirect their bad trip. Moreover, 90.5% of the sample The aim of this study was to examine the influence of extra- reported having had educational insights from the pharmacological factors in the emergence of the bad trip.

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Our sample was very heterogeneous, coming from different that they liked the style, whereas 7.8% did not like it. With countries and with unevenly aged strata. Because of this, we respect to the volume, we found more frequency of bad should carefully interpret the findings. trips when the music was at high or low volume (37.9% As far as we know, personality is a factor frequently and 23.7%, respectively), whereas contexts with music at associated with the development of a bad trip (Barrett, very high or very low volumes seem more “protective.” Johnson, & Griffiths, 2017; Grof, 2005; Lienert & Netter, Regarding that issue, Preller et al. (2017) reported that LSD 1996). The personality structure of our respondents was not could turn senseless music into beautiful music, suggesting assessed, but we observed that 22.4% of our sample had a that this factor might not be determinant for bad trips. Music psychiatric diagnosis prior to the occurrence of the bad trip. is a complex variable that must be studied in future research. This information is not enough to assert that people with Brightly lit spaces produced more bad trips (56.6%), but mental disorders are at higher risk of suffering a bad trip, but dark spaces are also inadequate (31.9%). It seems that the evidence supports the idea that this population is more best option is a soft, warm light that allows one to see susceptible (Cohen, 1960; Frosch et al., 1965; Robbins, properly/for clear vision. Frosch, & Stern, 1967; Strassman, 1984). We can ask our- LSD was the most reported drug (50%), but it is prob- selves about possible differences in the prevalence of mental lematic to state that LSD causes bad trips more frequently. disorders between our sample and the general population. In First, because the possibility exists that many more people in that case, we will have to face the difficulty of comparing the general take LSD than other drugs. In fact, a study by percentages observed in this study with the general prevalence Carvalho et al. (2014) produced very similar percentages in different countries, which could be different. In Colombia (53% of the sample took LSD). Second, we are mainly or Spain, the percentage of the population with psychiatric referring to the use of multiple drugs simultaneously: 67.2% diagnoses is similar (around 9%; Encuesta Nacional de Salud of the sample used more than one drug and 45% of the LSD Mental [ENSM], 2015; Instituto Nacional de Estadística users used other drugs. [INE], 2014). This value is well below that observed in our With respect to the dose, medium doses were responsible sample. For countries like Mexico, this information could not for more bad trips (21.6%), followed by high doses be found. It would also be interesting to compare the percent- (11.2%). Based on evidence gathered from this survey, it age of psychedelic consumers with psychiatric diagnoses who may be advisable to start with low doses until getting more never developed a bad trip to the percentage of consumers experience, as 48% of respondents had little prior experi- who did. This is a controversial debate, which is thoroughly ence with the drug. exemplified in Johansen and Krebs’s(2015)studyandthe Knowledge of dose and purity of the drug consumed is a subsequent replies (Nesvag, Bramness, & Ystrom, 2015). critical aspect in shaping the outcome of the trip. About 60% The majority of the sample (85.7%) came from recrea- of the sample did not know the dose that they took and 64% tional and festival contexts, so we can suggest that con- did not have information about the purity of the drug. Drug sumers who take psychedelic drugs in therapeutic contexts users need to have this information to predict and manage arelesslikelytosufferabad trip, but it is not possible to the effects and prevent most common complications. conclude that the consumption of psychedelics in therapeutic The findings about previous experience with the drug are contexts is favorable. We suggest considering the hypothesis quite interesting. We know that both experienced and naive that different contexts are chosen by different people, which users are at risk of suffering an acute adverse reaction implies a difficulty in associating certain contexts with (Robbins et al., 1967). However, the bigger percentage of concrete experiences. In addition, it is possible that people bad trips happened when the subject had little experience. who choose to take psychedelic substances in therapeutic We may propose the following hypothesis: new consumers contexts are more aware of the so-called “set and setting,” have more respect or fear in the face of a new drug, so they deliberately avoiding excessive noise, crowds, and other are more cautious. On the other side, subjects with plenty of potentially adverse stimuli. experience with the drug could be less prone to develop An indoor context seems to be more favorable to an adverse reactions, because they precisely know the common open outdoor setting. The occurrence of a bad trip was effects. But consumers with little experience can commit mildly higher in bigger settings. However, 44% of indi- the error of taking too big of a dose or not having enough viduals surveyed were with fewer than 10 people in the respect for the drug that they think they are familiar with. setting, which might seem contradictory. About 17.7% of the sample classified the bad trip experi- About 30.6% of the respondents reported that there was ence positively. We can understand this counterintuitive no music in the context. We can find recommendations of finding, if we consider the clinical observations of psyche- using music in the literature related to the therapeutic use of delic therapists. They have reported that the resolution of psychedelics (Bonny & Pahnke, 1972; Gaston & Eagle, psychologically challenging experiences may result in attri- 1970; Grof, 2005; Johnson et al., 2008), but we cannot bution of meaning, spiritual significance, and increased life extrapolate this information to the illicit use. Recently, satisfaction (Richards, 2015). Carbonaro et al. (2016)found Kaelen et al. (2015) found that one’s emotional response that same result in a bigger percentage (84%) of their sample. to music is enhanced by LSD, but that both positive and About 5.2% of respondents consumed medication with negative moods can be facilitated so consumers must be the intention of terminating the bad experience. Among cautious, especially if the music is not appropriately select- those, we found (1.7%), antipsychotic ed. An assumption about the role of music could be that it drugs (0.9%), caffeine (0.4%), or cocaine. The use of will facilitate more bad trips when people do not like the psychiatric medication should be considered only in cases style, but in this case, we found the contrary: 26.3% reported in which the psychological distress is insufficiently

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Unauthenticated | Downloaded 09/26/21 04:47 PM UTC Ona managed with reassurance (Johnson et al., 2008). In these We found some aspects that could be related to the cases, the pharmacological intervention of choice is benzo- appearance of a bad trip, but it is not possible to establish diazepines. Some antipsychotic drugs like can a causal connection. exacerbate the -like effects of psychedelic drugs, so We suggest that future studies on the topic include they should not be used as a rescue medication (Vollenweider, prospective methodologies and consider variables like per- Vollenweider-Scherpenhuyzen, Bäbler, Vogel, & Hell, 1998). sonality in the interest of producing more specific and The use of other drugs like caffeine or cocaine as a rescue reliable results. medication is strongly discouraged not only because of the non-specific action on the ending of psychedelic effects, but also because of the possible aggravation of the anxiety state and the unknown purity of these drugs. Funding sources: No funding was obtained from public or About 25.4% of our sample reported long-term side private institutions. effects and 44.8% experienced flashbacks. If we conceive the bad trip as a really challenging and traumatic experi- Author’s contribution: GO conceived and designed the ence, the presence of long-term side effects is to be survey, analyzed data, and wrote the paper. expected. In fact, this percentage is nearly the same as those found in other survey studies (Carbonaro et al., Conflict of interest: None. 2016). The percentage of flashbacks is much higher, reach- ing almost half of the sample. This is a very controversial phenomenon. Classic scientific literature suggests preva- lence between 15% and 77% among consumers of psyche- REFERENCES delic drugs (Blumenfield, 1971; Holsten, 1976; McGlothin & Arnold, 1971; Shick & Smith, 1970; Stanton & Bardoni, Abraham, H. D., & Aldridge, A. M. (1993). Adverse consequences 1972; Ungerleider et al., 1968). 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